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Archive for the ‘Acute flaccid myelitis (AFM)’ Category

CDC reports 18 more cases of the mysterious AFM in the week ending on Nov 30, bringing this year’s total to 134 cases confirmed in 33 states, among 299 cases reported, and the agency says the outbreak “appears to have peaked.”

States with confirmed cases of AFM, 2018 (N=116)

 


Increase in Acute Flaccid Myelitis — United States, 2018

MMWR

McKay SL, Lee AD, Lopez AS, et al. Increase in Acute Flaccid Myelitis — United States, 2018. MMWR Morb Mortal Wkly Rep. ePub: 13 November 2018. DOI: http://dx.doi.org/10.15585/mmwr.mm6745e1.

n August 2018, CDC noted an increased number of reports of patients having symptoms clinically compatible with acute flaccid myelitis (AFM), a rare condition characterized by rapid onset of flaccid weakness in one or more limbs and spinal cord gray matter lesions, compared with August 2017. Since 2014, CDC has conducted surveillance for AFM using a standardized case definition (1,2). An Epi-X* notice was issued on August 23, 2018, to increase clinician awareness and provide guidance for case reporting.

Patients who meet the clinical case criteria for AFM, defined as acute flaccid limb weakness, are classified using the Council of State and Territorial Epidemiologists case definitions of “confirmed” (magnetic resonance imaging [MRI] with spinal cord lesion largely restricted to gray matter and spanning ≥1 spinal segments), “probable” (cerebrospinal fluid [CSF] pleocytosis [>5 white blood cells per mm3]), or “not a case.”

Among 106 patients with acute flaccid limb weakness classified during January 1–November 2, 2018, 80 cases of AFM were classified as confirmed (from 25 states) (Figure), 6 as probable, and 20 as noncases. This represents a threefold increase in confirmed cases compared with the same period in 2017. Among confirmed cases, the median patient age was 4 years (range = 7 months–32 years; interquartile range [IQR] = 2.4–7.6 years), 47 (59%) were male, and, among 65 patients with information on race available, 56 (86%) were white. During the 4 weeks preceding the onset of limb weakness, signs and symptoms consistent with a viral illness were reported for 79 (99%), including fever for 65 (81%), respiratory symptoms (e.g., cough, rhinorrhea, and congestion) for 62 (78%), and gastrointestinal symptoms (e.g., vomiting and diarrhea) for 30 (38%) patients with confirmed AFM. Upper limb only involvement was reported by 38 (47.5%) patients, lower limb only by 7 (8.8%), two to three upper and lower limbs by 12 (15.0%), and all four limbs by 23 (28.8%). All patients with confirmed AFM were hospitalized, and 47 (59%) were admitted to intensive care units; no deaths have been reported.

Among 78 (98%) confirmed cases with available CSF results, 65 (83%) had pleocytosis, with a median cell count of 103 cells per mm3 (range = 6–814; IQR = 56–194); most had a lymphocyte predominance. Median CSF protein and glucose were 47 mg per dL (range = 8–289; IQR = 37–62; normal <45) and 59 mg per dL (range = 40–138; IQR = 52–65; normal ≥40), respectively. The median interval from limb weakness to CSF collection was 1 day (range = 0–16; IQR = 1–3). The median interval from sign or symptom onset to CSF collection was 7 days (range = 0–23; IQR = 5–8) for respiratory illness, 4 days (range = 0–22; IQR = 3–7) for gastrointestinal symptoms, and 3 days (range = 0–17; IQR = 2–6) for fever.

CDC conducts enterovirus/rhinovirus (EV/RV) testing for all patients meeting the clinical criteria for AFM, when specimens are available. Of the 80 confirmed cases in 2018, testing was performed on a total of 125 clinical specimens from 71 (89%) patients, including 21 CSF, 59 upper respiratory, and 45 stool/rectal swab specimens (Table). Among these, specimens from 38 (54%) patients were positive by EV/RV real-time reverse transcription–polymerase chain reaction testing, including 11 (29%) for EV-A71, 14 (37%) for EV-D68, and 13 (34%) for other viruses, primarily from nonsterile sites. CSF specimens from two patients were positive. One CSF specimen was positive for EV-A71; this patient also had a stool specimen positive for EV-A71. The second patient had a CSF specimen positive for EV-D68; this patient also had EV-D68 and parechovirus-A6 identified in a respiratory specimen. Two additional patients had more than one virus detected in a single respiratory specimen, including one with EV-D68 and echovirus 6 and one with RV-A24 and parechovirus-A6. All stool specimens tested negative for poliovirus. Among the 20 patients who did not meet the AFM case definition and were classified as non­cases, 1 (5%) had a positive CSF specimen (echovirus 25), 7 (35%) had positive respiratory specimens (EV-A71, RV-A24, RV-A56, RV-A90, EV/RV not typed), and 6 (30%) had positive stool or rectal swab specimens (EV-D68, EV-A71, RV-A90, echovirus 9, echovirus 11, echovirus 25).

Because some enteroviruses can cause acute flaccid limb weakness, and there was a temporal association with AFM and a nationwide severe respiratory outbreak of EV-D68 in 2014 (2), CDC performs EV/RV testing in an effort to identify etiologies for AFM cases. Despite a subsequent peak of AFM in 2016 (https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html), CDC did not receive reports of large outbreaks of severe respiratory illness in 2016. Further, there has been limited detection of pathogens in CSF in these cases; virus identified in CSF would be considered etiologic. Almost all patients with AFM have reported signs and symptoms consistent with viral illness in the weeks preceding limb weakness. Clinical, laboratory, and epidemiologic evidence to date suggest a viral association. CDC and collaborators continue to investigate risk factors for AFM and to study the causes and mechanisms of AFM.

Parents and caregivers are urged to seek immediate medical care for a child who develops sudden weakness of the arms or legs. In the evaluation of a child with acute flaccid limb weakness, clinicians are advised to inquire about recent fever with or without antecedent respiratory or gastrointestinal symptoms and to collect timely specimens for viral testing, including CSF, serum, respiratory, and stool specimens. Additional information for clinicians is available at https://www.cdc.gov/acute-flaccid-myelitis/hcp/index.html. Patients with acute flaccid limb weakness should be reported to their health departments as soon as possible regardless of laboratory or MRI findings.

 


From August 2014 through October 2018, CDC has received information on a total of 404 confirmed cases of AFM across the US; most of the cases have occurred in children.

CDC

Confirmed AFM cases reported to CDC: Aug-14 = 21, Sep-14 = 51, Oct-14 = 24, Nov-14 = 15, Dec-14 = 9, Jan-15 = 2, Feb-15 = 2, Mar-15 = 1, Apr-15 = 0, May-15 = 1, Jun-15 = 0, Jul-15 = 2, Aug-15 = 3, Sep-15 = 1, Oct-15 = 4, Nov-15 = 2, Dec-15 = 4, Jan-16 = 1, Feb-16 = 0, Mar-16 = 6, Apr-16 = 1, May-16 = 6, Jun-16 = 9, Jul-16 = 12, Aug-16 = 30, Sep-16 = 44, Oct-16 = 27, Nov-16 = 9, Dec-16 = 4, Jan-17 = 1, Feb-17 = 5, Mar-17 = 5, Apr-17 =3, May-17 =2, Jun-17 = 3, Jul-17 = 2, Aug-17 = 1, Sep-17 = 4, Oct-17 = 0, Nov-17 = 2, Dec-17 = 4, Jan-18 = 0, Feb-18 = 4, Mar-18 = 0, Apr-18 = 2, May-18 = 2, Jun-18 = 7, Jul-18 =6, Aug-18 = 18, Sep-18 = 23


CDC: So far in 2018, there are 72 confirmed cases of AFM.

CDC

Confirmed AFM cases reported to CDC: Aug-14 = 21, Sep-14 = 51, Oct-14 = 24, Nov-14 = 15, Dec-14 = 9, Jan-15 = 2, Feb-15 = 2, Mar-15 = 1, Apr-15 = 0, May-15 = 1, Jun-15 = 0, Jul-15 = 2, Aug-15 = 3, Sep-15 = 1, Oct-15 = 4, Nov-15 = 2, Dec-15 = 4, Jan-16 = 1, Feb-16 = 0, Mar-16 = 6, Apr-16 = 1, May-16 = 6, Jun-16 = 9, Jul-16 = 12, Aug-16 = 30, Sep-16 = 44, Oct-16 = 27, Nov-16 = 9, Dec-16 = 4, Jan-17 = 1, Feb-17 = 5, Mar-17 = 5, Apr-17 =3, May-17 =2, Jun-17 = 3, Jul-17 = 2, Aug-17 = 1, Sep-17 = 4, Oct-17 = 0, Nov-17 = 2, Dec-17 = 4, Jan-18 = 0, Feb-18 = 4, Mar-18 = 0, Apr-18 = 2, May-18 = 2, Jun-18 = 7, Jul-18 =6, Aug-18 = 18, Sep-18 = 23

At a Glance

  • CDC is concerned about AFM, a serious condition that causes weakness in the arms or legs.
  • From August 2014 through October 2018, CDC has received information on a total of 396 confirmed cases of AFM across the US; most of the cases have occurred in children.
  • Even with an increase in cases since 2014, AFM remains a very rare condition. Less than one in a million people in the United States get AFM each year.
  • While we don’t know the cause of most of the AFM cases, it’s always important to practice disease prevention steps, such as staying up-to-date on vaccines, washing your hands, and protecting yourself from mosquito bites.

Weekly Epidemiological Report from the Nigeria CDC

Nigeria CDC

In the reporting week ending on September 30, 2018:

o There were 173 new cases of Acute Flaccid Paralysis (AFP) reported. None was confirmed as polio. The last reported case of polio in Nigeria was in August 2016. Active case search for AFP is being intensified with the goal to eliminate polio in Nigeria.

o There were 2052 suspected cases of Cholera reported from 42 LGAs in seven States (Adamawa – 107, Borno – 702, Gombe – 90, Kaduna – 2, Katsina – 585, Yobe – 162 and Zamfara – 404). Of these, 26 were laboratory confirmed and 18 deaths were recorded.

o Nine suspected cases of Lassa fever were reported from seven LGAs in five States (Bauchi – 1, Edo – 5, FCT – 1, Nasarawa – 1 & Rivers – 1). Four were laboratory confirmed and no death was recorded.

o There were eight suspected cases of Cerebrospinal Meningitis (CSM) reported from five LGAs in five States (Ebonyi – 1, Edo – 2, Ondo – 2, Taraba – 1 & Yobe – 2). Of these, none was laboratory confirmed and no death was recorded.

o There were 124 suspected cases of measles reported from 30 States. None was laboratory confirmed and one death was recorded.

 


CDC: 62 cases of acute flaccid myelitis (AFM)

CDC

Acute flaccid myelitis (AFM) is a rare condition. It affects a person’s nervous system, specifically the spinal cord, causing weakness in one or more limbs. AFM or neurologic conditions like it have a variety of causes such as viruses, environmental toxins, and genetic disorders.

Since August 2014, CDC has seen an increased number of people across the United States with AFM. We have not confirmed the cause for the majority of these cases. CDC has been actively investigating these AFM cases, and we continue to receive information about suspected AFM cases.

Confirmed AFM cases reported to CDC: Aug-14 = 21, Sep-14 = 51, Oct-14 = 24, Nov-14 = 15, Dec-14 = 9, Jan-15 = 2, Feb-15 = 2, Mar-15 = 1, Apr-15 = 0, May-15 = 1, Jun-15 = 0, Jul-15 = 2, Aug-15 = 3, Sep-15 = 1, Oct-15 = 4, Nov-15 = 2, Dec-15 = 4, Jan-16 = 1, Feb-16 = 0, Mar-16 = 6, Apr-16 = 1, May-16 = 6, Jun-16 = 9, Jul-16 = 12, Aug-16 = 30, Sep-16 = 44, Oct-16 = 27, Nov-16 = 9, Dec-16 = 4, Jan-17 = 1, Feb-17 = 5, Mar-17 = 5, Apr-17 =3, May-17 =2, Jun-17 = 3, Jul-17 = 2, Aug-17 = 1, Sep-17 = 4, Oct-17 = 0, Nov-17 = 2, Dec-17 = 4, Jan-18 = 0, Feb-18 = 4, Mar-18 = 0, Apr-18 = 2, May-18 = 2, Jun-18 = 7, Jul-18 =6, Aug-18 = 18, Sep-18 = 23

 

Updated October 16, 2018

^ Confirmed AFM cases that CDC has been made aware of as of October 16, 2018 with onset of the condition through September 30, 2018. The case counts are subject to change.

* The data shown from August 2014 to July 2015 are based on the AFM investigation case definition: onset of acute limb weakness on or after August 1, 2014, and a magnetic resonance image (MRI) showing a spinal cord lesion largely restricted to gray matter in a patient age ≤21 years.

† The data shown from August 2015 to present are based on the AFM case definition adopted by the Council of State and Territorial Epidemiologists (CSTE): acute onset of focal limb weakness and an MRI showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments, regardless of age.

For more information, visit the Case Definitions page.

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What This Graph Shows

The graph shows the number of AFM cases confirmed by CDC as of October 16, 2018, with onset of the condition through September 30, 2018.

  • So far in 2018, there are 62 confirmed cases of AFM. (Note: The cases occurred in 22 states across the U.S.)
    Note: These 62 confirmed cases are among the total of 127 reports that CDC received of patients under investigation (PUIs). CDC recently received increased reports for PUIs with onset of symptoms in August and September. CDC and state and local health departments are still investigating some of these PUIs. With enhanced efforts working with local and state health departments and hospitals, we were able to confirm a number these cases faster. CDC is now providing the number of patients still under investigation so people can better anticipate increases in confirmed cases over the coming months.
  • In 2017, CDC received information for 33 confirmed cases of AFM. (Note: The cases occurred in 16 states across the U.S.)
  • In 2016, 149 people were confirmed to have AFM. (Note: The cases occurred in 39 states across the U.S. and DC)
  • In 2015, 22 people were confirmed to have AFM. (Note: The cases occurred in 17 states across the U.S.)
  • From August to December 2014, 120 people were confirmed to have AFM. (Note: The cases occurred in 34 states across the U.S.)
  • The case counts represent only those cases for which information has been sent to and confirmed by CDC.

It is currently difficult to interpret trends of the AFM data. Collecting information about suspected AFM cases is relatively new, and it is voluntary for most states to send this information to CDC. There may initially be more variability in the AFM data from year to year making it difficult to interpret or compare case counts between years.

We defer to the states to release additional information on cases as they choose.

Number of confirmed AFM cases by year of illness onset, 2014-2018*

Number of confirmed AFM cases by year of illness onset table
Year Number confirmed cases Number of states with confirmed cases
2014 (Aug-Dec) 120 34
2015 22 17
2016 149 39 (includes DC)
2017 33 16
2018 (Jan-Oct 16) 62 22

*The case counts are subject to change.

What We Know

Since 2014, CDC has learned the following about the AFM cases:

  • Most patients are children.
  • The patients’ symptoms have been most similar to complications of infection with certain viruses, including poliovirus, non-polio enteroviruses, adenoviruses, and West Nile virus.
    • All of the AFM cases have tested negative for poliovirus.
    • Enteroviruses most commonly cause mild illness. They can also cause neurologic illness, such as meningitis, encephalitis, and AFM, but these are rare.
  • CDC has tested many different specimens from AFM patients for a wide range of pathogens (germs) that can cause AFM. To date, no pathogen (germ) has been consistently detected in the patients’ spinal fluid; a pathogen detected in the spinal fluid would be good evidence to indicate the cause of AFM since this condition affects the spinal cord.
  • The increase in AFM cases in 2014 coincided with a national outbreak of severe respiratory illness among people caused by enterovirus D68 (EV-D68). Among the people confirmed with AFM, CDC did not consistently detect EV-D68 in every patient. During 2015, CDC did not receive information about large EV-D68 outbreaks in the United States, and laboratories reported only limited EV-D68 detections to CDC’s National Enterovirus Surveillance System (NESS). During 2016, CDC was informed of a few localized clusters in the United States. Learn more about EV-D68.

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What We Don’t Know

Among the people who were diagnosed with AFM since August 2014:

  • The cause of most of the AFM cases remains unknown.
  • We don’t know what caused the increase in AFM cases starting in 2014.
  • We have not yet determined who is at higher risk for developing AFM, or the reasons why they may be at higher risk.
  • We do not yet know the long-term effects of AFM. We know that some patients diagnosed with AFM have recovered quickly, and some continue to have paralysis and require ongoing care.

See prevention for information about how to protect your family from viruses that may cause AFM.

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What CDC Is Doing

CDC is actively investigating AFM cases and monitoring disease activity. We are working closely with healthcare providers and state and local health departments to increase awareness for AFM. We are encouraging healthcare providers to recognize and report suspected cases of AFM to their health departments, and for health departments to send this information to CDC to help us understand the nationwide burden of AFM. CDC is also actively looking for risk factors and possible causes of this condition.

CDC activities include:

  • urging healthcare providers to be vigilant for AFM among their patients, and to send information about suspected cases to their health departments
  • verifying clinical information of suspected AFM cases submitted by health departments, and working with health departments and neurologists to classify cases using a case definition adopted by the Council of State and Territorial Epidemiologists (CSTE)
  • testing specimens, including stool, blood, and cerebrospinal fluid, from suspected AFM cases
  • working with healthcare providers, experts, and state and local health departments to investigate and better understand the AFM cases, including potential causes and how often the condition occurs
  • providing new and updated information to healthcare providers, health departments, policymakers, the public, and partners in various formats, such as scientific journals and meetings, and CDC’s AFM website and social media
  • using multiple research methods to further explore the potential association of AFM with possible causes as well as risk factors for AFM. This includes collaborating with experts to review MRI scans of people from the past 10 years to determine how many AFM cases occurred before 2014, updating treatment and management protocols, and engaging with several academic centers to conduct active surveillance simultaneously for both AFM and respiratory viruses.

For more information, see


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